Provider Demographics
NPI:1841294709
Name:KELLEY, VENDA (ARNP)
Entity type:Individual
Prefix:MS
First Name:VENDA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 HANCOCK BRIDGE PKWY
Mailing Address - Street 2:STE. 301
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-7094
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2612
Practice Address - Street 1:2450 TAMIAMI TRL
Practice Address - Street 2:STE A
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-3922
Practice Address - Country:US
Practice Address - Phone:877-856-3774
Practice Address - Fax:239-599-2612
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9429926363LF0000X
KY3672P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
2237571OtherCCN
C60195OtherCUMBERLAND HEALTHCARE
KY000000226588OtherANTHEM
KY78007788Medicaid
KYA574OtherBC/BS
FL017319200Medicaid
FL6EFGAOtherBLUS CROSS BLUE SHIELD
KY1191652OtherCHA
KY500026005OtherRAILROAD MEDICARE
KY78007788Medicaid
KYP62593Medicare UPIN
FL017319200Medicaid